Mental Notes

Rethinking and rewriting the psychiatric rulebook


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Lee Anna Clark, a University of Notre Dame psychology professor, jumped at the chance to be involved in crafting the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in 2013.

“I saw this as a possible opportunity to see my research have real-world applications,” says Clark, who studies personality disorders and impairment assessment. Clark is one of several psychologists helping with the revision—the first since 1994.

Since the process began in 1999, the DSM-5 task force—and more than a dozen work groups, many of which include practicing psychologists—has been reviewing the current manual’s strengths and weaknesses, perusing the literature, and analyzing data. A draft of the DSM-5 proposes changes to the following categories:

Mood disorders. Add a new category called “temper dysregulation with dysphoria” to help clinicians distinguish between children with symptoms of severe mood dysregulation and those who have bipolar disorder or oppositional defiant disorder.

Suicide. Include new scales for adults and adolescents that may help clinicians identify patients at greatest risk.

Risk syndromes. Add a new diagnostic category called “risk syndromes,” which may help clinicians identify earlier stages of serious mental disorders such as dementia and psychosis.

Addiction. Replace the current categories of substance abuse and dependence with a new category called “addiction and related disorders” and add a new category called “behavioral addictions,” with gambling as its sole disorder.

Eating disorders. Change the criteria for diagnosing anorexia and bulimia. The proposed criteria for anorexia include a heightened focus on behavior, for example. While the DSM-IV’s diagnostic criteria include “refusal” and “fear of weight gain,” the eating disorders work group points out that “refusal” is difficult to assess and that some people with anorexia deny fear of weight gain. Additionally, make binge-eating disorder a freestanding diagnosis.

Learning disorders. Change the names of certain categories within the learning disorders section to bring them in line with international usage. Thus, the reading disorder and mathematics disorder categories become dyslexia and dyscalculia. The draft also recommends the creation of a single diagnostic category—autism spectrum disorders—to replace current diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder.

In addition to these changes, the DSM-5 draft proposes that “dimensional assessments” be added to diagnostic evaluations of mental disorders. These assessments would allow clinicians to evaluate the severity of symptoms and take into account symptoms that cut across multiple diagnoses.

“We know that anxiety is often associated with depression, for example, but the current DSM doesn’t have a good system for capturing symptoms that don’t fit neatly into a single diagnosis,” says David Kupfer, chair of the DSM-5 task force.

More than 8,000 clinicians, researchers, and family and patient advocates have commented on the draft, and the DSM-5 work groups are reviewing the comments to refine their recommendations. Overall, the APA predicts a fine-tuning of the DSM-IV rather than a complete overhaul.

The revision team has also launched field trials to test some of the proposed criteria in real-world settings. The trials will help ensure that the criteria are easy to understand and that they accurately describe mental illness in ways that help clinicians make sound treatment decisions.

Rebecca A. Clay is a writer based in Washington, D.C. Excerpted from Monitor on Psychology (Jan. 2011), the magazine of the American Psychological Association. Copyright © 2011 by the American Psychological Association. Adapted with permission. 

168-cover-thumb.jpgHave something to say? Send a letter to This article first appeared in the November-December 2011 issue of Utne Reader.